Correspondence between

michizan.goy)" "Lytle, Darren" <[email protected]>, "Fiedler, Jay (CDC michigan.zay)" <[email protected]>, "LaRocco, Toni™ <[email protected]>, "Henry, James" <[email protected]>, "Johnson, Mark (ATSDR/DCHI/CB)" <[email protected]>, "'Valacak, Mark" <MYALACAK@echdus>, "Johnson, Shannon (DHHS)" "Miller, Corinne (CDC michizan.gov)" <[email protected]>

(CDC/ONDIEH/NCEH) <zse1. Gicele.gov>; Johnson, Mark (ATSDR/DCHI/CB) <[email protected]>; Valacak, Mark <MVALACAK @echd.us>; Henry, James <[email protected]>; LaRocco, Toni <[email protected]>; Fiedler, Jay (CDC michigan.gov) <fledieri@ michigan. goy> OK, fet’s go ahead and schedule for Thurs Bec, 10 at 9:00 AM Eastern. ode: i. Here is a proposed agenda... fed free to weigh iron other items we should discuss. Specific to Legionnaires’ disease: What type of assistance Uf any} is being requested? (State and County HD) -jAihat is the role of £PA and what assistance has bean provided so far? {EPA} What is the role of ATSDR and what assistance has been provided so far? (ATSDR) if additional federal assistance is needed, what can COC offer? (COC) Thanks everyone! Laurel xxxEND_PAGE:dhhs03_b0210_0805_0807_3

irritation and tap water quality UK Drinking Water.pdf; SF Water 2013 Chloramines and skin irritation.pdf; Weintraub 2006 Hetergeneous dermatitis complaints after change in DW treatment Env Hith.pdf Hi Suzanne Thank you for the information on Legionella. For the non-lagionaila water issues, here are same documerts that might assist with thinking about complaints related to drinking water. The 2007 investigation in Vermont has some questions designed to assess health effects such as darrnatitis that might be helpful. However that investigation was very difficult, partly because some members of the community and outside groups attempted to Influence the results of the investigation. If you want te discuss that investigation further, | can contact the staff whe participated for their feedback. Hf you want to pursue these other complaints, it would be good to gather standard inforrnation on each cornplaint and categorize by syndrome, time, location, etc. You might already being doing this. We previously discussed syndramic surveillance; lam glad to discuss that further if you are interested. We don’t have experience doing that type of analysis in this situation but there might be athers who da. Regards Jonathan

Attached is additional information Shurood prepared yesterday to supplement cur conversation Information, it includes the number of canfirmed Legionella cases in Genesee County by calendar year. To clarify, the number we quoted for 2013 yesterday reflects our fiscal year which is October 2012-3013 and included confirmed and suspect cases. 1 xxxEND_PAGE:dhhs03_b0323_1188_1196_1 001189 Suzanne Cupal, M.PLH. Public Health Superviser Genesee County Health Department 630 S. Saginaw Street Suite 4 Flint, Mi 48502 (819) 788-7970

Thank you Susari and everyone for your work on this and for sharing your findings thus far, i will forward this te the rest of the group here, and we'll talk to you tornorrow at 9. laurel

Hello, Attached please find the survey data of cases interviewed by MDHHS and Genesee Co HD so far (Epiinfo analysis} and updated info on the investigation (MDHHS Prelim Stats}. We've included an agenda to help guide tomarraw morning's cali. Call dgenda Summarizing the ® Prehminary Statistics MBHHS (Shannon & Susan} e interview Data MDHHS {Lily & Meghan} o EPI info Analysis @ £Pi Curve GCHD e © Biscussion of Current investigation Au Environmental investigation e Environmental Sampling Protocal cb xxxEND_PAGE:dhhs03_b0323_1188_1196_2 001190 e Piscussic All Additional Recommendations # Additional Recornmendatians COC/AH THi tomorrow then, Susan Bohm, M5 Manager, Enteric & Respiratory Hinesses Epidemiology Unit Surveillance and infectious Disease Epicerniology Division of Communicable Disease Michigan Department of Health and Hurnan Services 201 Townsend 3t, Sth Fir Lansing, Mi 48933 (sh and may iden sd fcs ithe senda! nf vephy e-rail ard

Thanks, Suzanne. in just looking at this quickly, Pr wondering Hf you can you break down the epi curve in the following ways: -~Colar code the cases with exposure to McLaren during their incubation periods --Color code by sorne kind of indicator of exposure to Flint water (maybe G.3?). You've probably already looked at this in several different ways, and | think there are other ways to took at it as well, but perhaps that might help us. Thanks!

| ust forwarded information. Please let us know if there is anything else we can share. Suzanne Cupal, MPH, Public Health Supervisor Genesee County Health Department 630 &. Saginaw Street Suite 4 xxxEND_PAGE:dhhs03_b0323_1188_1196_3 001191 Flint, Mi 48502 {810} 788-7970 soupal@achd us

Hi all, dust checking in to see whether you expect to send any ep! data to help guide the discussion tomorrow. ifwe could review it prior to the call] think that would help facilitate the call and ensure we make the must of our time. Thanks! Laurel

Hello, Yes, 9:00 or 9:30 on Thursday works for us. Let us know the final details when they're decided. O# the topics mentioned below, at this point in time it would be best to focus or: » the current investigation, e® CDC walk-through of the environmental sarnniing protecal, @ anda discussion of any additional recommendations. it's very likely that these topics wil fil our allotted time. There’s no need te discuss the clinical specimen collection and guidance that has already been provided to GCHD and sent te local providers. The syndramic surveillance data project 4 xxxEND_PAGE:dhhs03_b0323_1188_1196_4 001192 would be better handied at the focal/state level and should not take away from the ongoing epi investigation that we're currently assisting GCHD with. Thanks, and we look forward te hearing from you. --fay Jay Fiedler, MS Section Manager Surveillance and Infectious Disease Epidemiology Bureau of Disease Control, Prevention, and Epidemiology Michigan Department of Health and Hurnan Services 201 Townsend St - PO Box 301795 - Lansing, ME 48909 P) 517, 335.9516 - E: fledleriGimichigan.gov Confidentiality Notice: This message, including any attachments, is intended solely for the use of the named recipient(s) and may contain confidential and/or privileged information. Any unauthorized review, use, disclosure or distribution of this communication(s) is expressly prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy any and all copies of the original message.

Thursday morning works for us. Suzarine Cupal, MPH. Public Healin Supervisor Genesee County Health Department 630 S. Saginaw Sireat Sule 4 Fini, Mi 48502 {810} 788-7970 scupal@achd us

xxxEND_PAGE:dhhs03_b0323_1188_1196_5 001193 Hi Suzanne, Yes, let’s try to schedule something for this week. Would Thursday morning work for everyone? Yes, it would be helpful to be able to review your epi curve, questionnaire results, ete. prior to the call, Thanks, Laurel

Hi Suzanne, lmet with colleagues and leadership at CDC, and we are very concerned about this Legionnaires’ disease outkreak. it’s very large, one of the largest we know of in the past decade, and community-wide, and in our opinion and experience it needs a comprehensive investigation. i know you all have been working on this for quite a while, but we are unclear 6 xxxEND_PAGE:dhhs03_b0323_1188_1196_6 001194 about which steps have been taken and what is currently known, and we feel a sense of urgency. is it possible to meet before May 8? it's difficult to give advice when we don’t have ali the information, but we are eager to help. You may have already taken several of these steps, but we recornmend a full investigation including the following steps: ~-Generate an epi curve, man the cases, interview ali cases with a hypothesis-generating questionnaire, analyze results

Hello Suzanna, Looking at our schedules, we have limited availability of our core staff here at DHHS an Friday May 8°. In order to help prioritize or to determine if we should iook fer an alternate meeting time, can we get an idea of what the agenda will be for this call? Thanks, -lay Jay Fiedler, MS Section Manager xxxEND_PAGE:dhhs03_b0323_1188_1196_7 001195 Surveillance arid Infectious Disease Epidemiciogy Bureau of Disease Contra, Prevention, and Epidernicioay Michigan Departraent of Health and Human Services 204 Townsend Sk - PO Box 30795 - Lansing, MF 48909 Confidentiality Notice: This message, including any attachments, is intended solely for the use of the named recipient(s) and may contain confidential and/or privileged information. Any unauthorized review, use, disclosure or distribution of this communication(s) is expressly prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy any and all copies of the original message.

Our team is available an Friday, May 8° at Llam if that would work for you and our state colleagues. Thank you for your assistance. Suzanne Suzanne Cupal, LPH. Public Health Supervisor Genesee County Health Department 830 S. Saginaw Street Suite 4 Flint, Mi 48502 (819) 768-7970 scupal@achd us

Hi Suzanne af al., Hf you are interested in discussing the Legionella action items in more detail, please let me know your availability for a conferance call involving the county, state, and RDB. Rest regards, Laurel Laurel Garrison, MPH Legionellosis Surveillance & Outbreak Resporse NCIRD/DBD/Respiratory Diseases Branch Centers for Disease Control and Prevention 1600 Cifton Rd, ME MS C-25 Atlanta, GA 30333 404.639.3434 fLaes@icde gov xxxEND_PAGE:dhhs03_b0323_1188_1196_8 001196

Hi Suzanne It was good to speak to you yesterday. | am copying Laurel on this email as the contact for the legionella program. She will coordinate with the state to make sure you have the protocols. We are glad to assist. Jonathan Sent from my iPhone Jonathan- Thank you and your team for the opportunity to speak yesterday. We appreciate your comments about a measured response. We recognize we do not have the data we need for further action. We were grateful for the opportunity to share with you and our state colleagues our concerns based on the information we do have. We are doing everything we can to mitigate risk to our residents. We look forward to receiving the sampling protocols and advice related to syndromic surveillance. Our concerns have now been communicated which opens the door to further communication as events unfold. We are dealing with complex and confounding information. We appreciate your assistance in gathering the facts. We want to be prepared to protect the health and safety of our residents and provide appropriate information. Thank you again. Your Genesee County Colleagues Suzanne Cupal, M.P.H. Public Health Supervisor Genesee County Health Department 630 S. Saginaw Street Suite 4 Flint, MI 48502 (810) 768-7970 xxxEND_PAGE:dhhs03_b0323_1188_1196_9